Job Description:
• Evaluate clinical requests from providers to determine whether care is medically appropriate and aligned with established criteria and protocols
• Conduct inpatient, concurrent, benefit advisory/prior authorization, retrospective, out-of-network, and treatment-setting medical necessity reviews
• Assess medical necessity of inpatient admissions, outpatient services and procedures, benefit applications, and out-of-network provider requests
• Consult with Medical Directors when requested care does not meet applicable criteria or policies
• Document clinical information completely, accurately, and on time
• Meet or exceed productivity and quality standards
• Maintain knowledge of provider and member contracts, authorization requirements, InterQual Guidelines, medical policies, and clinical criteria
• Identify opportunities to connect members with appropriate Clinical Programs
• Collaborate with Customer Service/Claims Operations, Sales and Marketing, and Health Care Services
• Ensure Utilization Management decisions and turnaround times comply with accreditation and regulatory requirements
• Support the Plan’s Quality Program through quality improvement initiatives, programs, processes, studies, and projects
Requirements:
• Bachelor's degree or 4 years’ work experience (Required)
• Current state licensure as a Registered Nurse (Required)
• WA or Compact RN license (Preferred)
• 3 years of clinical experience (Required)
• Utilization Review experience (Preferred)
• Experience working in the health plan industry (Preferred)
• Ability to work Monday through Friday or Tuesday through Saturday, 8:00 a.m. to 5:00 p.m. Pacific Time
• Ability to keyboard and communicate clearly and understandably in person and over the telephone
• Ability to perform sedentary work and occasionally exert up to 10 lbs. of force
Benefits:
• Medical, vision, and dental coverage with low employee premiums
• Voluntary benefit offerings, including pet insurance
• Life and disability insurance
• Retirement programs, including a 401K employer match and pension plan vested after 3 years of service
• Wellness incentives, including mental well-being resources, counseling services, stress management programs, and mindfulness programs
• Generous paid time off
• Tuition assistance for undergraduate and graduate degrees
• Employee recognition program
• Commuter perks
• Free convenient on-site parking
• Subsidized on-campus cafes
• On-site health and wellness activities
• Fitness and well-being center with in-person and virtual workouts and nutritional counseling